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Destructive operations in obstetrics


									                              J Obstet Gynecol India Vol. 56, No. 2 : March/April 2006    Pg 113-114

                                                           EDITORIAL                                    The Journal of
                                                                                     Obstetrics and Gynecology
                                                                                                                   of India

                                Destructive operations in obstetrics

Unduly prolonged obstructed labor with the fetus jammed in          hemorrhage and one from severe postoperative shock after
the pelvic cavity beyond any hope of spontaneous delivery is        cesarean section. Six percent had vaginal lacerations and 3%
not seen in the developed countries today. But such a situation     urinary or wound infections. They state that their 0.094%
is prevalent in the developing countries across the continents.     incidence of obstructed labor was lower than 0.24 to 0.283%
. It plagues thousands of women every year and accounts             reported from other Indian hospitals. They found that women
for 8% of maternal deaths in developing countries 1 . In India      were referred late from the PHCs and emphasised the need
70% of our population lives in rural areas with barely any          to train the PHC doctors in performing craniotomy,
modern obstetric facilities. Antenatal care is mostly not           decapitation and evisceration. In 2001 Biswas et al 3 from
available or not availed of for various reasons. Home deliveries    Kolkata, reported a 1.17% (141 in 12,034 deliveries over a
with untrained female attendant is almost a norm. In India          year) incidence of obstructed labor – 0.29% or 36 with dead
50% deliveries lack skilled or trained assistance. When labor       fetus. 44.4% underwent craniotomy and 55% evisceration.
gets obstructed due to contracted pelvic and fetal                  Cephalopelvic disproportion was the commonest cause of
malformation or malpresentation the pauturient, as an               obstruction. There was one traumatic rupture of the uterus
inevitable last recourse, is taken to the nearest primary health    but no maternal death.
center (PHC) which is often quiet a distance away requiring
time consuming arduous journey. The arriving parturient often       In 2005 Singhal et al 4 , from a medical college hospital in
merits the description of a woman in neglected obstructed           Haryana, reported 51 destructive operations done for
labor with a dead fetus and distressed mother with                  obstructed labor with dead fetus over a 7 year period. Of
dehydration, advanced infection and a uterus desperately            these 68.62% women had craniotomies, 19.60% had
trying to surmount the obstruction. The PHCs, more often            decapitation, 7.84% had evisceration and 3.92% had
than naught, lack necessary skilled obstetric and anesthetic        cleidotomy.Cephalopelvic disproportion was the commonest
services, and adequate surgical and ancilliary facilities like      indication. Two fetuses were groosly malformed, 49.05%
blood transfusion to deal with the ordeal of the suffering          weighed between 3 and 4 kg, and 9.43% were macrosomic.
parturient who just needs a simple craniotomy or cleidotomy         49.09% women developed complications like atonic
or a difficult decapitation or evisceration or a prompt cesarean    postpartum hemorrhage, vaginal and perineal tears, puerperal
section with all its morbidity. Unable to offer these life saving   sepsis, and urinary infection. There was no maternal death.
procedures the woman is sent on another ordeal of a long            The authors rightly conclude that destructive operation is a
and difficult journey, consuming very precious time, to reach       good option even today. Adhikari et al 5 from a Medical College
a tertiary health care center usually attached to a medical         hospital in Kolkata report in 2005 a 0.56% incidence of
college. Cesarean delivery is often resorted to as an easier        obstructed labor (245/43906 deliveries) from January 1993
way out in preference to destructive operations, often for          to December 1998. 63.27% or 155 were delivered by
want of training and skill in conducting these rewarding            cesarean section and 36.73% or 90 had destructive operations
procedures.                                                         - 67 craniotomies (60 for cephalopelvic disproportion, four
                                                                    for hydrocephalus and three for arrested after coming head),
Arora et al 2 from a medical college hospital Pondicherry           21 decapitations and two eviscerations.
reported in 1999, 33 destructive operations performed
between 1981 and 1991 – 27 craniotomies, two decapitations,         Of the 94 (38.37%) women with dead fetus eight were
three eviscerations and one cleidotomy. In three cases the          delivered by cesarean section. In all 12 cesarean babies died
procedure failed needing cesarean section. Indications for          within 30 minutes of birth. Five mothers died after
craniotomy were hydroceplalus (52%), obstructed labor               craniotomy, not because of craniotomy but due to
(19%), arrested after coming head (7%), cord prolapse (5%),         complications of eclampsia. 7.09 (11/158) had complications
persistent mentotransverse (4%), and placental abruption            after cesarean rectus - wound infection, urinary infection,
(4%). There were two maternal deaths one from postpartum            and hematoma in the broad ligament or rectus sheath.


Amongest the 90 destructive operations there were two           hospital to a PHC for 6-12 months. Incidently, this deputed
vesicoaginal and two rectovaginal fistulas, and 15 genital      person will also improve the overall obstetric skill of the PHC
tears - a complication rate of 21.11% (19/90). The authors      doctor and the obstetric services offered at the PHC.
advocate an individualized approach to obstructed labor.
Gupta and Chitra 6 from a Medical College hospital in Delhi
                                                                1.   Cron J. Lesson from the developing world : obstructed labor and the
compared 56 destructive operations for women arriving late           vesico-vaginal fistula. Ob/Gyn and Women’s Health. Medscape General
in obstructed labor with a dead fetus done between 1985 and          Medicine 003;50:2003. Medscape Posted 08/14/2003.
1991 with 27 cesarean sections done in 1989 and 1990 for
                                                                2.   Arora R, Rajaram P, Oumachigui A et al. Destructive operations in
similar indications. They found that destructive operations          modern obstetrics in a developing country at tertiary level. Br J Obset
had no maternal death, few complications, and short hospital         Gynecol 1993;100:967-8.
stay while cesarean section had one maternal death, long        3.   Biswas A, Chakraborty PS, Das HS et al. Role of destructive operations
hospital stay, need for blood transfusion, and more                  in modern day obstetrics. J Indian Med Assoc 2001;99:248-51.
complications. They rightly concluded that destructive          4.   Singhal SR. Chaudhary P, Sangwan K et al. Destructive operations in
operations not only have a place in developing countries but         modern obstetrics. Arch Gynecol Obstet 2005;273:107-9.
when feasible are safer than cesarean deliveries. Reports
                                                                5.   Adhikari S, Dasgupta M, Sanghmita M. Management of obstructed
from Africa project a similar picture, quoting the incidence         labor: a retrospective study. J Obstet Gynecol India 2005;55:48-51.
of obstructed labor as 1.27% (207/16221) 7, 0.96% (380/
                                                                6.   Gupta U, Chitra R. Destructive operations still have a place in
39456) 8 and 4.7% (527/11299) 9.                                     developing countries. Int J Gynaecol Obstet 1994;44:15-9.
                                                                7.   Dafallah SE, Ambago J, El-Aguib F. Obstructed labor in a teaching
Although obstructed labor in banished from the western world
                                                                     hospital in Sudan. Saudi Med J. 2003;24:1102-4.
where the destructive operations are obsolete and not needed,
in developing countries like India obstructed labor with dead   8.   Konje JC, Obisesan KA, Ladipo OA,. Obstructed labor in Ibadan. Int J
                                                                     Gynaecol Obstet. 1992;39:17-21.
fetus and severe infection is a sad reality, and destructive
operations are an essential part of obstetric practice and      9.   Ozumba BC, Uchegbu H. Incidence and management of obstructed
cannot be wished away. In many situations they should be a           labour in eastern Nigeria. Aust NZJ Obstet Gynecol 1991;31:213-6.

preferred option to cesarean delivery which needs much better
facilities and greater morbidity. There in a great need for
training PHC doctors in performing destructive operations                                        Mahendra N. Parikh
and in judging situations where these are apt. This can best                                     43 Vasant , Off Carter Road
be done by deputing a competent person from a teaching                                           Khar, Mumbai 400 052
                                                                                                 Tel. : 022-26001465 /26484052


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